Validated scoring system identifies low-risk syncope patients

To examine 30-day outcomes, researchers reviewed all available patient medical records, including administrative health records at all hospitals within the province; performed a telephone follow-up immediately after 30 days; and if no other information was found, searched the coroner’s database. Two ED physicians (with a third resolving disagreements) determined if a serious outcome occurred, including any arrhythmia, intervention to treat arrythmia, death due to an unknown cause, myocardial infarction, structural heart disease, aortic dissection, pulmonary embolism, severe pulmonary hypertension, significant hemorrhage, or subarachnoid hemorrhage.¹

A total of 4131 patients made up the validation cohort. A serious condition was identified during the initial ED visit in 160 patients (3.9%), who were excluded from the study, and 152 patients (3.7%) were lost to follow-up. Of the 3819 patients included in the final analysis, troponin was not measured in 1566 patients (41%), and an electrocardiogram was not obtained in 114 patients (3%). A serious outcome within 30 days was experienced by 139 patients (3.6%; 95% CI, 3.1%-4.3%). There was good correlation to the model-predicted serious outcome probability of 3.2% (95% CI, 2.7%-3.8%).¹

Three of 1631 (0.2%) patients classified as very low risk and 9 of 1254 (0.7%) low-risk patients experienced a serious outcome, and no patients died. In the group classified as medium risk, 55 of 687 (8%) patients experienced a serious outcome, and there was 1 death. In the high-risk group, 32 of 167 (19.2%) patients experienced a serious outcome, and there were 5 deaths. In the group classified as very high risk, 40 of 78 (51.3%) patients experienced a serious outcome, and there were 7 deaths. The CSRS was able to identify very low– or low-risk patients (score of −1 or better) with a sensitivity of 97.8% (95% CI, 93.8%-99.6%) and a specificity of 44.3% (95% CI, 42.7%-45.9%).¹

WHAT’S NEW

This scoring system offers a validated method to risk-stratify ED patients

Previous recommendations from the American College of Cardiology/American Heart Associationsuggested determining disposition of ED patients by using clinical judgment based on a list of risk factors such as age, chronic conditions, and medications. However, there was no scoring system.³ This new scoring system allows physicians to send home very low– and low-risk patients with reassurance that the likelihood of a serious outcome is less than 1%. High-risk and very high–risk patients should be admitted to the hospital for further evaluation. Most moderate-risk patients (8% risk of serious outcome but 0.1% risk of death) can also be discharged after providers have a risk/benefit discussion, including precautions for signs of arrhythmia or need for urgent return to the hospital.

CAVEATS

The study does not translate to all clinical settings

Because this study was done in EDs, the scoring system cannot necessarily be applied to urgent care or outpatient settings. However, 41% of the patients in the study did not have troponin testing performed. Therefore, physicians could consider using the scoring system in settings where this lab test is not immediately available.

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